Do in-service training materials for midwifery care providers in sub-Saharan Africa meet international competency standards? A scoping review 2000-2020.

BACKGROUND: Levels of maternal and neonatal mortality remain high in sub-Saharan Africa, with an estimated 66% of global maternal deaths occurring in this region. Many deaths are linked to poor quality of care, which in turn has been linked to gaps in pre-service training programmes for midwifery care providers. In-service training packages have been developed and implemented across sub-Saharan Africa in an attempt to overcome the shortfalls in pre-service training. This scoping review has aimed to summarize in-service training materials used in sub-Saharan Africa for midwifery care providers between 2000 and 2020 and mapped their content to the International Confederation of Midwives (ICM) Essential Competencies for Midwifery Practice. METHODS: Searches were conducted for the years 2000-2020 in Cumulative Index of Nursing and Allied Health Literature, PubMed/MEDLINE, Social Science Citation Index, African Index Medicus and Google Scholar. A manual search of reference lists from identified studies and a search of grey literature from international organizations was also performed. Identified in-service training materials that were accessible freely on-line were mapped to the ICM Essential Competencies for midwifery practice. RESULTS: The database searches identified 1884 articles after removing duplicates. After applying exclusion criteria, 87 articles were identified for data extraction. During data extraction, a further 66 articles were excluded, leaving 21 articles to be included in the review. From these 21 articles, six different training materials were identified. The grey literature yielded 35 training materials, bringing the total number of in-service training materials that were reviewed to 41. Identified in-service training materials mainly focused on emergency obstetric care in a limited number of sub-Saharan Africa countries. Results also indicate that a significant number of in-service training materials are not readily and/or freely accessible. However, the content of in-service training materials largely met the ICM Essential Competencies, with gaps noted in the aspect of woman-centred care and shared decision making. CONCLUSION: To reduce maternal and newborn morbidity and mortality midwifery care providers should have access to evidence-based in-service training materials that include antenatal care and routine intrapartum care, and places women at the centre of their care as shared decision makers.

Assessment of midwifery care providers intrapartum care competencies, in four sub-Saharan countries: a mixed-method study protocol.

BACKGROUND: We aim to assess competencies (knowledge, skills and attitudes) of midwifery care providers as well as their experiences and perceptions of in-service training in the four study countries; Benin, Malawi, Tanzania and Uganda as part of the Action Leveraging Evidence to Reduce perinatal mortality and morbidity in sub-Saharan Africa project (ALERT). While today more women in low- and middle-income countries give birth in health care facilities, reductions in maternal and neonatal mortality have been less than expected. This paradox may be explained by the standard and quality of intrapartum care provision which depends on several factors such as health workforce capacity and the readiness of the health system as well as access to care. METHODS: Using an explanatory sequential mixed method design we will employ three methods (i) a survey will be conducted using self-administered questionnaires assessing knowledge, (ii) skills drills assessing basic intrapartum skills and attitudes, using an observation checklist and (iii) Focus Group Discussions (FGDs) to explore midwifery care providers' experiences and perceptions of in-service training. All midwifery care providers in the study facilities are eligible to participate in the study. For the skills drills a stratified sample of midwifery care providers will be selected in each hospital according to the number of providers and, professional titles and purposive sampling will be used for the FGDs. Descriptive summary statistics from the survey and skills drills will be presented by country. Conventional content analysis will be employed for data analysis of the FGDs. DISCUSSION: We envision comparative insight across hospitals and countries. The findings will be used to inform a targeted quality in-service training and quality improvement intervention related to provision of basic intrapartum care as part of the ALERT project. TRIAL REGISTRATION: PACTR202006793783148-June 17th, 2020.

Midwifery care providers' childbirth and immediate newborn care competencies: A cross-sectional study in Benin, Malawi, Tanzania and Uganda.

Evidence-based quality care is essential for reducing sub-Saharan Africa's high burden of maternal and newborn mortality and morbidity. Provision of quality care results from interaction between several components of the health system including competent midwifery care providers and the working environment. We assessed midwifery care providers' ability to provide quality intrapartum and newborn care and selected aspects of the working environment as part of the Action Leveraging Evidence to Reduce perinatal morTality and morbidity (ALERT) project in Benin, Malawi, Tanzania, and Uganda. We used a self-administered questionnaire to assess provider knowledge and their working environment and skills drills simulations to assess skills and behaviours. All midwifery care providers including doctors providing midwifery care in the maternity units were invited to take part in the knowledge assessment and one third of the midwifery care providers who took part in the knowledge assessment were randomly selected and invited to take part in the skills and behaviour simulation assessment. Descriptive statistics of interest were calculated. A total of 302 participants took part in the knowledge assessment and 113 skills drills simulations were conducted. The assessments revealed knowledge gaps in frequency of fetal heart rate monitoring and timing of umbilical cord clamping. Over half of the participants scored poorly on aspects related to routine admission tasks, clinical history-taking and rapid and initial assessment of the newborn, while higher scores were achieved in active management of the third stage of labour. The assessment also identified a lack of involvement of women in clinical decision-making. Inadequate competency level of the midwifery care providers may be due to gaps in pre-service training but possibly related to the structural and operational facility characteristics including continuing professional development. Investment and action on these findings are needed when developing and designing pre-service and in-service training. Trial registration: PACTR202006793783148-June 17th, 2020.

Are midwives ready to provide quality evidence-based care after pre-service training? Curricula assessment in four countries-Benin, Malawi, Tanzania, and Uganda.

This research sought to map midwifery pre-service training curricula as part of the Action Leveraging Evidence to Reduce perinatal morTality and morbidity in sub-Saharan Africa (ALERT) project conducted in Benin, Malawi, Tanzania, and Uganda. We conducted the review in two phases. In the first phase, online interviews were performed with the lead project midwives in all four study countries to get an overview of midwifery care providers' pre-service training courses, registration, and licensing requirements. We performed a mapping review of midwifery care providers' pre-service training curricula from different training institutions in the four study countries during the second phase. Curricula were reviewed and mapped against the International Confederation of Midwives (ICM) Essential Competencies framework to assess whether these curricula included the minimum essential training components described in the ICM framework. We identified 10 different professional titles for midwifery care providers. The number of years spent in pre-service training varied from one and a half to four years. Ten pre-service curricula were obtained and the assessment revealed that none of the curricula included all ICM competencies. Main gaps identified in all curricula related to women-centred care, inclusion of women in decision making, provision of care to women with unintended or mistimed pregnancy, fundamental human rights of individuals and evidence-based learning. This review suggests that there are skills, knowledge and behaviour gaps in pre-service training curricula for midwifery care providers when mapped to the ICM Essential Competencies framework. These gaps are similar among the different training courses in participating countries. The review also draws attention to the plethora of professional titles and different pre-service training curricula within countries. Trial registration: PACTR202006793783148-June 17th, 2020.

Protocol for a scoping review to identify and map in-service education and training materials for midwifery care in sub-Saharan Africa from 2000 to 2020.

INTRODUCTION: Maternal and neonatal mortality are disproportionally high in low-and middle-income countries. In 2017 the global maternal mortality ratio was estimated to be 211 per 100 000 live births. An estimated 66% of these deaths occurred in sub-Saharan Africa. Training programmes that aim to prepare providers of midwifery care vary considerably across sub-Saharan Africa in terms of length, content and quality. To overcome the shortfalls of pre-service training and support the provision of quality care, in-service training packages for providers of midwifery care have been developed and implemented in many countries in sub-Saharan Africa. We aim to identify what in-service education and training materials have been used for providers of midwifery care between 2000 and 2020 and map their content to the International Confederation of Midwives' Essential Competencies for Midwifery Practice (ICM Competencies), and the Lancet Midwifery Series Quality Maternal and Newborn Care (QMNC) framework. METHODS AND ANALYSIS: A search will be conducted for the years 2000-2020 in Cumulative Index of Nursing and Allied Health Literature, PubMed/MEDLINE, Social Sciences Citation Index, African Index Medicus and Google Scholar. A manual search of reference lists from identified studies and a hand search of literature from international partner organisations will be performed. Information retrieved will include study context, providers trained, focus of training and design of training. Original content of identified education and training materials will be obtained and mapped to the ICM Competencies and the Lancet Series QMNC. ETHICS AND DISSEMINATION: A scoping review is a secondary analysis of published literature and does not require ethical approval. This scoping review will give an overview of the education and training materials used for in-service training for providers of midwifery care in sub-Saharan Africa. Mapping the content of these education and training materials to the ICM Competencies and The Lancet Series QMNC will allow us to assess their appropriateness. Findings from the review will be reflected to stakeholders involved in the design and implementation of such materials. Additionally, findings will be published in a peer-reviewed journal, and used to inform the design and content of an in-service training package for providers of midwifery care as part of the Action Leveraging Evidence to Reduce perinatal morTality and morbidity (ALERT) study, (https://alert.ki.se/) a multi-country study in Benin, Malawi, Tanzania and Uganda. TRIAL REGISTRATION NUMBER: PACTR202006793783148; Post-results.

Unique and proforma birth plans: a qualitative exploration of midwives׳ experiences.

BACKGROUND: birth plans detailing a woman׳s preferences for intrapartum care are a common feature in British maternity units, and are a means of encouraging the implementation of choice. Proforma versions may be incorporated routinely in antenatal case notes, or the woman may devise her own unique birth plan. Although women׳s views of birth plans have been explored, the views of midwives have not to date been evaluated. The growth of midwife-led units in the UK has highlighted different philosophies of care, some of which can be reflected in the different types of birth plan. Given the increasingly diverse nature of UK midwifery workplaces we set out to explore and compare the experience of midwives working in midwife-led and obstetric-led settings in relation to unique and proforma birth plans. METHOD: qualitative study using focus groups of midwives in a midwife-led unit (MLU; n=5) and obstetric-led unit (OLU; n=4) in the East of England. We used an interpretative phenomenological analytical approach. FINDINGS: three main themes arose from the data. Firstly, the term 'birth plan' can be misleading, and was criticised for encouraging the belief that birth can be 'planned'. In addition, midwives claimed that 'unique' birth plans, especially those influenced by some consumer advocacy groups, are becoming standardised in their rejection of policies and procedures and requests for intervention-free birth. Secondly, birth plans were a source of irritation for midwives in both groups, although the cause of the irritation differed between groups. Finally, it was found that midwives in both groups felt that birth plans put pressure on them, although again, the source of the pressure, and therefore the way in which midwives reacted to this pressure, differed between groups. CONCLUSIONS: the term 'birth plan' can be misleading and create false expectations. If 'unique' birth plans are becoming 'standardised' in the sense that they routinely request the same things, they are little different to proforma birth plans. Some midwives perceive pressure both from women and the wider multidisciplinary team as a result of birth plans, a perception that causes some irritation.